tbuckley/cabot-search huggingface dataset:
PD09 A prospective study of outcomes of narrowband ultraviolet B for the treatment of paediatric atopic dermatitis, with additional breakdown by ethnicity/skin type
Authors: Pavan Sambi, Katharine Warburton, Rachel Montgomery, Parisha Majeethia, Mia Thompson, Sheila Clark
Journal: British Journal of Dermatology (2023)

Abstract Narrowband UVB (NBUVB) phototherapy is regarded as a second-line treatment for atopic dermatitis (AD) when response to first-line treatment is ineffective. We undertook a prospective study evaluating response to NBUVB treatment in paediatric AD to assess changes to pretreatment Eczema Area and Severity Index (EASI) score immediately postphototherapy and 12 months later. We subanalysed response in different skin types. All patients had NBUVB treatment three times weekly up to a maximum of 40 exposures. Follow-up was every 3 months for 1 year postphototherapy. In total, 58 patients were recruited for NBUVB phototherapy treatment [37 (64%) men, 21 (36%) women, mean age 10.6 years (range 4.1–16.9 years)]. Skin types/ethnicity were as follows: White, n = 22 (38%); South Asian (Pakistani/Indian/Bangladeshi), n = 17 (29%); Black African/Caribbean, n = 9 (16%); other, n = 10 (17%). The immediate post-treatment mean EASI reductions vs. pretreatment baseline scores were 10.0 (entire cohort), 12.4 (White), 8.6 (South Asian), 2.5 (Black African/Caribbean) and 7.5 (other). A ≥ 75% increase in EASI (EASI 75) was achieved in the 49% of the entire cohort, in 48% of White people, in 50% of South Asians, in 44% of Black African/Caribbean people and in 56% of others. A ≥ 90% increase in EASI (EASI 90) was achieved in 15% of the whole group, 14% of White people, 13% of South Asians, 22% of Black African/Caribbean people and 11% of others. At 12 months post-treatment, mean EASI reduction vs. pretreatment baseline score was 7.6 in the whole cohort, 9.0 in White people, 8.6 in South Asians, −2.1 (i.e. worsening) in Black African/Caribbean people and 8.0 in others. At 12 months post-treatment, EASI 75 was achieved in 28% of the whole group, 33% of White people, 40% of South Asians, 14% of Black African/Caribbean people and 13% of others. For those who responded, there were a similar proportion of those achieving EASI 75 across the different skin types. However, there was more variation in the reduction in EASI score in those with skin colour. We acknowledge that existing scoring systems may lead to underscoring of the severity of erythema and therefore overall EASI score in darker skin types. Although the mean EASI reduction was highest in the group of White patients, there was a higher proportion of Black/Caribbean patients achieving EASI 90 at the end of the NBUVB treatment; however, the overall number of patients in this group was small. Our study showed that White and South Asian paediatric patients had a more sustained response to NBUVB phototherapy up to 1 year after stopping treatment. Black African/Caribbean patients had a greater risk of relapse.
PD12 An audit of the photodynamic therapy service at the Birmingham Skin Centre
Authors: Taherah Khan, Fatima Dalal, Michelle Thomson
Journal: British Journal of Dermatology (2023)

Abstract Photodynamic therapy (PDT) is licensed in the UK for treating at least one nonmelanoma skin cancer and premalignant lesions. The PDT is a service offered at our centre but is anecdotally underutilized with no up-to-date outcome measures. The aim was to audit the PDT service at the Birmingham Skin Centre against the 2018 British Association of Dermatologists and British Photodermatology Group PDT guidelines, and make recommendations for improvement. Retrospective data were gathered on consecutive patients treated with topical PDT between 12 March 2019 and 28 August 2022 at the Birmingham Skin Centre and compared with the recommended audit points in the national guidelines. A clinician survey was conducted to assess service awareness, satisfaction and referral process. Thirty-four patients received topical PDT during the specified time period; two patients were excluded from data analysis as the last treatment fell within the 3-month assessment period (n = 32). Differentiation between ambulatory and standard PDT was not recorded. Treatment was licensed in all cases (n = 32): actinic keratosis (AK; n = 18), squamous cell carcinoma (SCC; n = 7) in situ, superficial basal cell carcinoma (BCC; n = 4), nodular BCC (n = 1) and other (n = 2). Clearance assessment at 3 months was recorded in 21 of 32 cases; accounting for this, the clearance rate for AK, SCC in situ and superficial BCC at 3 months after last treatment was 52% (n = 11/21; guideline recommendation ≥ 75%). Eleven of 32 patients treated for SCC in situ and superficial BCC within the data set were due 12-month clearance assessment. Four of 11 patients had clearance assessment recorded. Accounting for this, the clearance rate for SCC in situ and superficial BCC at 12 months after last treatment was 50% (n = 2/4; guideline recommendation ≥ 75%). No patient had an individual pain-management plan documented. Patient satisfaction of the service was recorded in 9% (n = 3/32) of cases; of these, 67% (n = 2/3) of patients were ‘very satisfied’ and 33% ‘satisfied’. Patient satisfaction of cosmetic result was recorded in one case as ‘excellent’. The PDT was a popular treatment method among the clinicians surveyed. Some clinicians asked for PDT-based teaching. The general consensus supported online referrals and documentation. The PDT is used for licensed indications and popular with clinicians in our department. Clearance rates at 3 (52%) and 12 (50%) months are below the national guideline recommendation of 75%. Limited documentation across audit points limits interpretation of clearance rates, patient satisfaction and adverse effects. We plan to implement a new standardized digital referral and documentation system to improve the service.
P68 Liver fibrosis is independent of methotrexate use in patients with moderate-to-severe psoriasis
Authors: Parastoo Babakinejad, Rebecca Lapsley, Lara Foster, Stuart McPherson, Mark Pearce, Nick Reynolds, Emma Slack, Sophie Weatherhead, Philip Hampton
Journal: British Journal of Dermatology (2023)

Abstract Methotrexate has been implicated for liver disease in patients with psoriasis for many years. Liver fibrosis (LF) has various established risk factors, but data on the impact of methotrexate on LF in patients with psoriasis are lacking. This cross-sectional cohort study aimed to determine the prevalence of LF using noninvasive LF markers in patients with psoriasis, and to evaluate the relationship between LF and the cumulative dose of methotrexate and other liver disease risk factors. Adults with moderate-to-severe chronic plaque psoriasis diagnosed by a dermatologist, who were selected for a LF assessment, were recruited from dermatology clinics in a tertiary centre between June 2020 and March 2021. Data were recorded as part of standard clinical care and at the time of recruitment. Patients underwent transient elastography to evaluate LF. Three values for liver stiffness measurement (LSM) were used, indicating ≥ mild LF (≥ 7 kPa), ≥ moderate LF (≥ 7.9 kPa) and ≥ advanced LF (≥ 9.5 kPa). Both continuous and categorical LSM values were used for evaluation. A total of 225 patients were included [median age 48, interquartile range (IQR) 37–57, 51% female]. Fifty-six per cent had a body mass index (BMI) ≥ 30 kg m−2, and the median alcohol use disorders identification test (AUDIT) score was 4 (IQR 1–7, 23% score ≥ 8). Ninety-one per cent had received methotrexate for a median duration of 36 months (IQR 14–78). Prevalence rates of LF were 31%, 21% and 13% using LSM ≥ 7 kPa, ≥ 7.9 kPa and ≥ 9.5 kPa, respectively. There was no association between methotrexate and continuous LSM values [unadjusted coefficient 0.16, 95% confidence interval (CI) 0.49–0.82; P = 0.63] or using the categorical LSM cutoff values: 7 kPa (unadjusted coefficient 1.06, 95% CI 0.98–1.15; P = 0.19), 7.9 kPa (unadjusted coefficient 1.03, 95% CI 0.94–1.12; P = 0.58) and 9.5 kPa (unadjusted coefficient 1.01, 95% CI 0.91–1.12; P = 0.84). Similarly, no significant relationship was found when adjusting for other risk factors for LF. The following risk factors were associated with higher LSM values: BMI (P &amp;lt; 0.001), waist circumference (P &amp;lt; 0.001), metabolic syndrome (P &amp;lt; 0.001), AUDIT score (P = 0.020) and Fib-4 score (P = 0.03). This study confirms a high prevalence of significant LF in patients with moderate-to-severe psoriasis. More importantly, it shows that cumulative methotrexate was not associated with LF, and other risk factors including BMI, waist circumference, metabolic syndrome, alcohol intake and Fib-4 score are important predictors for LF. The findings suggest that these risk factors should be assessed in this group of patients to identify patients requiring regular liver health monitoring. Further research is needed to determine whether methotrexate contributes to the progression of LF in the context of pre-existing LF.
BI07 Outcomes of oral squamous cell carcinoma following haematopoietic stem cell transplantation
Authors: Faaris Zaki, Martina Shephard, Robert Danby, James Davies, Rachel Pawson, Andy Peniket, Rubeta Matin
Journal: British Journal of Dermatology (2023)

Abstract Haematopoietic stem cell transplant (HSCT) recipients are at increased risk of malignancies, including cancers of the oral cavity, with a reported observed-to-expected ratio of 10.7, accounting for 14% of all solid tumours following HSCT. We report 10 cases of oral squamous cell carcinoma (SCC; 2016–2022) in HSCT recipients from a single tertiary centre [nine men and one woman; median age at diagnosis 52 years (range 27–66)]. Thirty per cent were ex-smokers and 10% current smokers. Prior to HSCT, 50% had reduced intensity conditioning, 40% had myeloablative conditioning and 10% had both. Eighty per cent were recipients of sibling allografts and 20% were recipients from matched unrelated donors. Ninety per cent had a history of chronic graft-versus-host disease (GVHD), with affected sites including the mouth (n = 6), skin (n = 6), eyes (n = 5), lungs (n = 4), kidneys (n = 3) and liver (n = 1). Forty per cent had active severe manifestations of oral GVHD. Treatments used for oral GVHD included topical immunosuppression (n = 5), oral immunosuppression (n = 6) and extracorporeal photopheresis (ECP; n = 2). Median latency from HSCT to oral SCC diagnosis was 10 years (range 4–22). At the time of SCC diagnosis, 20% were not taking immunosuppressants, 20% were being treated with topical corticosteroids and 50% with oral immunosuppression, and one patient was recently treated with ECP. Examination findings at SCC diagnosis included induration, ulceration, tenderness, bleeding, hyperkeratosis, speckling and lymphadenopathy (n = 1). Fifty per cent were asymptomatic. In 40% of cases, a previous biopsy showed hyperplastic or dysplastic changes. The commonest sites of SCC were the tongue (n = 4) and buccal mucosa (n = 3). The disease stage (TNM) at presentation ranged from T1N0M0 to T4N2M0. Sixty per cent of cases were T3 or T4 and 40% had nodal involvement. Management included radical surgical resection in 90% of cases; 10% received adjuvant radiotherapy and 10% chemoradiotherapy. One patient with an SCC on the lower lip underwent resection using Mohs micrographic surgery. Median duration of follow-up for the cohort was 0.8 years (range 0.4–5.7) with a 50% mortality rate. In our cohort, median survival following oral SCC diagnosis was 0.8 years (range 0.4–5.0) and SCC-specific mortality was 30% (n = 3). We report the largest UK case series, to the best of our knowledge, of oral SCC post-HSCT. The data show a long latency from HSCT to the onset of oral SCC, highlighting the importance of regular, active oral surveillance by haematologists, dermatologists, oral specialists and dentists. This follow-up is recommended irrespective of the severity of GVHD and length of iatrogenic immunosuppression. Intensive surveillance is indicated in groups at higher risk with a history of chronic oral GVHD.
PD04 Real-life experience of Scottish patients with idiopathic solar urticaria
Authors: Alexandra McMullan, Andrea Lesar, Sally Ibbotson
Journal: British Journal of Dermatology (2023)

Abstract We conducted a retrospective study to characterize our most recent cohort of patients with idiopathic solar urticaria (SU), to compare with our previous findings (Beattie PE, Dawe RS, Ibbotson SH, Ferguson J. Characteristics and prognosis of idiopathic solar urticaria: a cohort of 87 cases. Arch Dermatol 2003; 139:1149–54). We analysed data derived from our in-house database and paper and electronic records of patients with SU seen through the Scottish Photobiology Service between 2003 and 2022. Eighty-four patients with SU were seen in this period, 57 (68%) women and 27 (32%) men. Twenty-nine (35%) had a single consultation/phototesting and 55 (65%) had follow-up assessments. The average age of onset was 37 years, with the average age of diagnosis being 41 years, with delays from symptom onset to diagnosis ranging from 6 months to 24 years. Importantly, 20 (24%) patients self-reported systemic symptoms, most commonly fatigue, dizziness and nausea. Of 61 patients using antihistamines before diagnosis, 31 (51%) reported benefit. Of patients who tried sunscreens, 31 of 65 (48%) reported benefit. On monochromator phototesting, sensitivity predominantly involved the ultraviolet (UV)A waveband (335–400 + 27 nm in 55%), extending into the visible spectrum (&amp;gt; 430 + 27 nm) in 44% and UVB waveband (305 + 5 nm) in 1%, consistent with previous reports of predominant UVA/visible light dependency in SU. On review of follow-up data, we analysed the fold benefit in minimal urticaria dose (MUD) from testing on H1 antihistamines alone, H1 and H2 antihistamines combined and the addition of montelukast. Most (65%) responded with a more than twofold improvement in MUD after a single dose of H1 antihistamine, with only 35% not responding. Increasing the dose of H1 antihistamine did not provide notable additional benefit. There was a suggestion of improved responses by the addition of an H2 antagonist (in 76% vs. 66% with H1 antagonist alone), but this was not statistically significant (P &amp;gt; 0.05). No additional improvement in threshold sensitivity (MUD) was observed by the addition of montelukast. Small numbers of patients used other treatments such as photo(chemo)therapies and systemic immunosuppressants, and these were found to be of limited benefit. Since 2011, we have used omalizumab for patients with treatment-resistant SU. Of the current cohort, 13 received omalizumab, with 62% reporting a good clinical response and a further 15% a partial clinical response. Phototesting in these patients showed complete abolition of photosensitivity or excellent responses (more than fivefold increase in MUD) in 73%, demonstrating the efficacy of omalizumab in recalcitrant SU. Given the systemic features reported by some patients with SU, this supports a management approach, which includes systemic immunomodulation as a potentially effective option.
CPC06 Congenital urticaria pigmentosa mistaken for nonaccidental injury
Authors: Emma Porter, Cynthia Heffron, Lesley Ann Murphy, Cathal O’Connor
Journal: British Journal of Dermatology (2023)

Abstract A male infant presented to his general practitioner for a routine 6-week check. His parents reported the presence of tan–brown lesions since birth. The marks were uniform in colour, were present on the trunk, scalp and face, and were not overlying bony prominences. There was concern that these lesions represented bruising as a manifestation of nonaccidental injury (NAI), and urgent paediatric review was arranged. He was admitted for investigation of potential NAI, and dermatology consultation was sought. On examination, scattered reddish brown-to-tan macules and papules were noted on the torso and limbs, not overlying bony prominences. Darier sign was negative, although some reactive cutis marmorata was appreciable on the trunk following rubbing of multiple lesions. A diagnosis of urticaria pigmentosa (UP), or cutaneous mastocytosis, was made clinically. Skin biopsies demonstrated an infiltrate of spindled and round mast cells and scattered eosinophils within the superficial and mid-dermis, with immunohistochemistry positive for CD117, consistent with UP. Blood tests during admission showed a normal complete blood count and coagulation screen (including von Willebrand factor), normal renal and liver function, normal lactate dehydrogenase, normal immunoglobulins and normal mast cell tryptase. Cranial ultrasound and liver ultrasound were normal. Mastocytosis is a spectrum of disease characterized by pathological accumulation of mast cells in tissues, including skin, bone marrow and the gastrointestinal tract. Cutaneous mastocytosis can be further classified as maculopapular cutaneous mastocytosis, also known as UP, diffuse cutaneous mastocytosis and localized cutaneous mastocytomas. With UP, children typically present in the first 2 years of life with multiple reddish-brown macules, papules and/or plaques distributed anywhere on the body, most commonly the trunk. In darkly pigmented skin, lesions may be hyperpigmented and erythema less appreciable. Darier sign, a transient urticarial response upon gentle rubbing of the skin, is classic and supportive of diagnosis, although it is not always demonstrable. UP has rarely been reported to be misdiagnosed as NAI. Other ‘bruising’ mimics include disorders of coagulation, Valsalva petechiae, vasculitis, acute haemorrhagic oedema, incontinentia pigmenti, phytophotodermatitis, coin rubbing, spooning, cupping, Mongolian spots, morphoea, neuroblastoma and ink stains, some of which may be unfamiliar to paediatricians or dermatologists. Dermatologists have a crucial role in recognizing cutaneous manifestations of NAI in children, which commonly includes bruising, particularly in infants who are not yet mobile. While consideration of NAI is important in all children presenting for medical care, this case highlights the importance of considering underlying dermatoses to avoid unwarranted distress and unnecessary investigations.
H12 Royal rashes: a potted dermatology history in the British monarchy
Authors: Charlotte Wolfe, Rachel Fisher
Journal: British Journal of Dermatology (2023)

Abstract Skin diseases have affected a significant proportion of the population throughout history, royalty being no exception. On reviewing monarchs over the centuries, underlying health conditions can be gleaned from their reported skin conditions and physical appearance. In the 14th century, King Henry IV seized the throne from his cousin Richard II. Henry IV was debilitated by a skin disease thought to be leprosy or severe psoriasis, believed to be a punishment from God for being the first king to execute an archbishop. He is reported to have developed great pustules and eventually necrotic ulcers. King Henry VIII, famous for his six wives, also suffered with poor health during his reign from 1509 to 1547. By the age of 44 years, he was reportedly significantly obese, suffering from bilateral leg ulcers that became recurrently infected, leaving him unable to walk. The aetiology of the king’s ulceration may encompass a range of potential diagnoses. It is likely to have been as a result of venous disease with stasis dermatitis alongside trauma and obesity. Henry’s daughter Queen Elizabeth I, who reigned from 1558 to 1603, suffered from smallpox in 1562, which left her face scarred. Her physical scars were concealed with early forms of lead-laced makeup. She also reportedly suffered from hair loss. This may have been telogen effluvium secondary to stress, or it is possible that she suffered from female pattern hair loss. Alternatively, the application of lead to her face may have contributed to her alopecia. The following century, Queen Anne, the monarch that unified England and Scotland and took ownership of Gibraltar, is thought to have suffered from systemic lupus erythematosus. Portraits have demonstrated the classic malar rash, facial oedema and joint swellings. She also suffered many miscarriages and eventually a lethal stroke, raising suspicion for associated antiphospholipid syndrome. Moving to the 20th century, Prince William of Gloucester, a grandson of King George V, suffered from a photoexacerbated blistering skin rash. Three years later, he was diagnosed with porphyria, giving credence to the theory that the madness of King George III, one of William’s ancestors, was due to porphyria. However, this has been disputed, and manic–depressive psychosis is felt to be the more likely explanation. With up to 33% of the UK population suffering with skin conditions at any one time, a significant number of the current royal family will have a variety of skin diseases. How will their dermatological history be told in the future?
BI22 Successful treatment of antitumour necrosis factor-α-induced paradoxical palmoplantar pustulosis with tofacitinib
Authors: Gregg Murray, Rory Barry, Muireann Roche
Journal: British Journal of Dermatology (2023)

Abstract Palmoplantar pustulosis (PPP) is an inflammatory skin condition characterized by eruptions of sterile pustules on the palms and/or soles. These eruptions cause significant discomfort and have a major impact on a patient’s quality of life. The exact cause of PPP remains unknown; several theories have been hypothesized. These theories include genetic factors, including mutations in IL36RN, associations with autoimmune/autoinflammatory disorders and drug-induced aetiologies. Tumour necrosis factor (TNF)-α inhibitors are widely used in the treatment of autoimmune conditions such as psoriasis, psoriatic arthritis, rheumatoid arthritis and inflammatory bowel disease. An unusual side-effect of these treatments is their ability to induce paradoxical reactions. It is reported in the literature that this can occur in 2–5% of patients receiving TNF-α inhibition. We report a case of anti-TNF-α-induced paradoxical PPP in a 52-year-old woman with rheumatoid arthritis (RA). Three months after commencing adalimumab for her RA, the patient developed painful sterile pustules on her palms and soles. She was a smoker with no previous history of psoriasis. Her adalimumab treatment was discontinued, and her hands and feet were treated with clobetasol propionate. Despite 3 months of topical treatment and discontinuation of adalimumab, her PPP deteriorated. Interleukin (IL)-17 or IL-23 inhibition was considered but is not indicated for the treatment of RA. To gain control of both her RA and PPP, she was started on tofacitinib 5 mg twice daily, a partial and reversible JAK1 and JAK3 inhibitor. Within 4 days, the pustulosis on her hands and feet improved, and within 3 months, she had total disease clearance with a complete response. Her Dermatology Life Quality Index improved from 23/30 to 0/30. The patient developed a dental abscess on treatment. During this infection, her tofacitinib was withheld for 2 weeks and was treated with metronidazole. During this period, she had an acute flare of her PPP, which quickly resolved once recommencing tofacitinib. In a recent systematic review, a total of 155 patients with biologic-associated paradoxical PPP were identified, with the most common cause being TNF-α inhibition, with female sex, smoking and concomitant autoimmune disorders being major risk factors. To date, only five case reports have described the successful treatment of PPP with tofacitinib. We found that tofacitinib is an effective and rapid treatment for paradoxical PPP.